Provider Demographics
NPI:1417099318
Name:SUN WEST DENTAL III, LLC
Entity Type:Organization
Organization Name:SUN WEST DENTAL III, LLC
Other - Org Name:SUN WEST DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-640-0267
Mailing Address - Street 1:1601 W APACHE TRL STE 2
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85120-3769
Mailing Address - Country:US
Mailing Address - Phone:602-354-5800
Mailing Address - Fax:602-354-5860
Practice Address - Street 1:1601 W APACHE TRL STE 2
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85120-3769
Practice Address - Country:US
Practice Address - Phone:480-982-4200
Practice Address - Fax:480-982-4220
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUN WEST DENTAL CENTER III, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-14
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD4013122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty